| NPI | 1255717237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35101) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 9658) |
| Enumeration Date | 2015-07-31 |
| Last Update Date | 2022-07-05 |